State Health O˜cer’s Report on E-Cigarettes

1 State Health O cer s Report on E-Cigarettes A Community Health reatEdmund G. Brown Jr., GovernorState of CaliforniaDiana S. Dooley, SecretaryCalifornia Health and Human Services AgencyState Health Officer s Report on E-Cigarettes A Community Health ThreatRon Chapman, MD, MPHCDPH Director and State Health OfficerCalifornia Department of Public HealthJa nu a r y 2 015 Suggested CitationCalifornia Department of Public Health , California Tobacco Control Program, State Health Officer s Report on E-Cigarettes : A Community Health Threat, Sacramento, CA 2015iIntroduction from the State Health OfficerAs the California Department of Public Health (CDPH) Director and State Health Officer, I am pleased to present CDPH s second issue of the State Health Officer s Report which focuses on electronic cigarettes ( E-Cigarettes ).

2 While there is still much to be learned about the individual and public Health impact of e-cigarette use, this Report provides factual information about E-Cigarettes , the marketing of these products, and the public Health concerns related to their use. It outlines a number of steps to protect children from nicotine poisoning, adolescents from nicotine addiction, and non-users from exposure to the toxic aerosol emitted from the State Health Officer, of particular concern to me is the impact of E-Cigarettes on the Health and safety of children, teens, and young adults. The availability of E-Cigarettes in a variety of candy and fruit flavors such as cotton candy, gummy bear, chocolate mint, and grape makes these products highly appealing to young children and teens.

3 The use of marketing terms such as e-juice may further mislead consumers into believing that these products are harmless and safe for consumption. Among children ages 0 to 5 years old, e-cigarette poisonings increased sharply from 7 in 2012 to 154in 2014. By the end of 2014, e-cigarette poisonings to young children tripled in one year, making upmore than 60 percent of all e-cigarette poisoning use is rapidly rising among teens and young adults. Nationally, the use of e cigarettes by high school students tripled in just two years and e-cigarette use by teens now surpasses the use of traditional cigarettes . With this age group the long-term impact that nicotine has on adolescent brain development is of particular concern.

4 In California, use among young adults ages 18 to 29 tripled in one year. While the long term Health impact resulting from use of this product by this population is presently unknown it is known that E-Cigarettes emit at least 10 chemicals that are found on California s Proposition 65 list of chemicals known to cause cancer, birth defects, or other reproductive harm. Comprehensive steps taken now can prevent a new generation of young people from becoming addicted to nicotine, avoid future Health disparities and avert an unraveling of California s approximately $2 billion, 25-year investment in public Health efforts to prevent and reduce tobacco use in California.

5 This Report highlights several steps to address the Health and safety issues related to e-cigarette use. First and foremost, education is needed to counter the marketing of E-Cigarettes which is often misleading and highly appealing to teens. Second, there is a need to treat E-Cigarettes in a comprehensive manner Ron Chapman, MD, MPHCDPH Director and State Health Officerthat is consistent with how we approach traditional cigarettes . Existing laws that currently protect minors and the general public from traditional tobacco products should be extended to cover E-Cigarettes . Third, immediate action is needed to protect children and workers from the toxicity associated with unintentional exposure and handling of e-liquid and the toxic aerosol emitted from trust that this Report provides you with new information and that you will join me in this effort to protect our communities.

6 Si nc erely,Ron Chapman, MD, MPHCDPH Director and State Health OfficeriiiCONTENTSE xecutive Summary ..1 The Problem: E-Cigarettes ..3 A Significant Public Health Concern ..3 E-Cigarette Use by Youth ..4 E-Cigarette Use by Adults ..5 Health Effects of Nicotine ..5 Exposure to Secondhand Aerosol ..6 Harm Reduction Claims and Myths about Cessation ..6 Unrestricted Marketing ..7 Where E-Cigarettes are Sold in California ..8 Local Efforts ..11 Summary of FDA Proposed Regulation ..13 Public Education Campaign on E-Cigarettes ..15 Conclusions ..17 References ..191 State Health Offfcer s Report on E-Cigarettes : A Community Health ThreatExecutive SummaryWhile there is still much to be learned about the ingredients and the long-term Health impacts of E-Cigarettes , this Report provides Californians with information on e-cigarette use, public Health concerns related to E-Cigarettes , and steps that can be taken to address the growing use of these products.

7 The following are key highlights from the Report :E-Cigarette Use In 2014, teen use of E-Cigarettes surpassed the use of traditional cigarettes for the first time, with more than twice as many 8th and 10th graders reporting using E-Cigarettes than traditional cigarettes . Among 12th graders, 17 percent reported currently using E-Cigarettes vs. 14 percent using traditional cigarettes . In California, adults using E-Cigarettes in the past 30 days doubled from percent in 2012 to percent in 2013. For younger adults (18 to 29 years old), e-cigarette use tripled in only one year from percent to percent. Young adults are three times more likely to use E-Cigarettes than those 30 and older.

8 Nearly 20 percent of young adult e-cigarette users in California have never smoked traditional cigarettes . Health Effects of E-Cigarettes E-Cigarettes contain nicotine, a highly addictive neurotoxin. Exposure to nicotine during adolescence can harm brain development and predispose youth to future tobacco use. E-Cigarettes do not emit water vapor, but a concoction of chemicals toxic to human cells in the form of an aerosol. The chemicals in the aerosol travel through the circulatory system to the brain and all organs. Mainstream and secondhand e-cigarette aerosol has been found to contain at least ten chemicals that are on California s Proposition 65 list of chemicals known to cause cancer, birth defects, or other reproductive Concern for Youth The variety of fruit and candy flavored E-Cigarettes entice small children who may accidently ingest them.

9 Even a fraction of e-liquid may be lethal to a small child. E-cigarette cartridges often leak and are not equipped with child-resistant caps, creating a potential source of poisoning through ingestion and skin or eye contact. Calls to poison control centers in California and the rest of the have risen significantly for both adults and children accidently exposed to e-liquids. In California, the number of calls to the poison control center involving e-cigarette exposures in children five and under tripled in one Health Offfcer s Report on E-Cigarettes : A Community Health ThreatHarm Reduction Claims and Myths There is no scientific evidence that E-Cigarettes help smokers successfully quit traditional cigarettes .

10 E-cigarette users are no more likely to quit than regular smokers, with one study finding 89 percent of e-cigarette users still using them one year later. Another study found that e-cigarette users are a third less likely to quit Marketing In three years, the amount of money spent on advertising E-Cigarettes increased more than 1,200 percent. E-cigarette advertisements (ads) are on television (TV) and radio where tobacco ads were banned more than 40 years ago. Most of the methods being used today by e-cigarette companies were used long ago by tobacco companies to market traditional cigarettes to kids. Many ads State that E-Cigarettes are a way to get around smoking bans, which undermines smoke free social norms.